an adult client with severe depression was admitted to the psychiatric unit yesterday evening although the client ran one year ago his spouse states t
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Nursing Elites

HESI LPN

CAT Exam Practice Test

1. An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client used to run a year ago, his spouse states that the client no longer runs but sits and watches television most of the day. Which is most important for the nurse to include in this client’s plan of care for today?

Correct answer: A

Rationale: Assisting the client in identifying goals for the day is the most important aspect of the plan of care for a client with severe depression. Setting achievable daily goals helps engage the client in activities and promotes a sense of accomplishment, which can contribute to gradual improvement in their condition. Encouraging participation in team sports may be overwhelming for a client with severe depression as it requires a significant level of energy and motivation that the client may not possess at this time. Group sessions focusing on self-esteem and daily affirmations are beneficial interventions, but they may not have an immediate impact compared to setting achievable daily goals that can provide a sense of purpose and achievement for the client.

2. Three hours following a right carotid endarterectomy, the nurse notes a moderate amount of bloody drainage on the client’s dressing. Which additional assessment finding warrants immediate intervention by the nurse?

Correct answer: B

Rationale: Tongue deviation to the left is the correct answer. It could indicate a complication such as nerve injury or hematoma, which requires immediate attention. A sore throat when swallowing may be expected postoperatively but does not indicate an immediate complication. Palpable temporal pulses are a normal finding and do not require immediate intervention. A temperature of 99.2°F (37.3°C) is slightly elevated but does not suggest a critical issue related to the surgery.

3. A client receiving chemotherapy has severe neutropenia. Which snack is best for the nurse to recommend to the client?

Correct answer: A

Rationale: The correct answer is A: Plain yogurt sweetened with raw honey. This option is the best choice for a client with severe neutropenia undergoing chemotherapy because it is less likely to harbor harmful bacteria, which could cause infections due to the weakened immune system. Peanuts in the shell (choice B) may carry a risk of contamination, while aged farmer's cheese with celery sticks (choice C) and baked apples topped with dried raisins (choice D) may not be as safe as plain yogurt for a client with severe neutropenia.

4. A client is receiving lidocaine IV at 3 mg/minute. The pharmacy dispenses a 500 ml IV solution of normal saline (NS) with 2 grams of lidocaine. The nurse should regulate the infusion pump to deliver how many ml/hour?

Correct answer: D

Rationale: The infusion rate is calculated based on the concentration of lidocaine and the prescribed rate of infusion. First, convert lidocaine's weight to milligrams (2 grams = 2000 mg). Then, use the formula: (Total volume in ml * dose in mg) / 60 minutes. For this case, (500 ml * 2000 mg) / 60 minutes = 45 ml/hour. Therefore, the correct answer is D. Choices A, B, and C are incorrect as they do not reflect the accurate calculation based on the provided concentration and infusion rate.

5. An older male resident of a long-term care facility has been scratching his legs for the past 2 days. Which intervention should the nurse implement?

Correct answer: D

Rationale: The correct intervention for the nurse to implement in this scenario is to apply emollient to the affected area at least twice daily. This is because applying emollients helps address dry skin, which is a common cause of itching in older adults. Explaining the importance of bathing or showering daily (Choice A) may be helpful for general hygiene but may not specifically address the itching. Encouraging fluid intake (Choice B) and keeping the legs covered (Choice C) are not directly related to addressing the itching caused by dry skin.

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